Diagnosis can be confirmed by incising one of the papules, smearing the contents from the center of a papule between two glass slides, staining (with Wright’s, Giemsa’s or Gram’s stain), and then viewing diagnostic anucleate homogeneous ovoid “molluscum bodies” under low magnification.
When the clinical findings are confusing and the smear is negative, do a biopsy.

How do you treat Molluscum Contagiosum?

Children: conservative, non-scarring methods
Adults: genital lesions should be treated definitively to prevent spread by sexual contact
New lesions that are too tiny for detection may appear after treatment and may require additional treatment.

How is molluscum contagiosum spread?

Lesions are spread by autoinoculation from picking or rubbing or shaving
Advise patients against such things while lesions are present

Veruca Vulgaris

What pertinent history questions do you want to ask about warts?

Ask if the patient is taking a mediation that may decrease cell-mediated immunity (i.e. prednisone, cyclosporine, chemotherapeutic agents)
Ask if the patient is a transplant recipient (these patients have warts that can be very resistant to treatment)
Ask if the patient handles raw meat, fish, or other types of animal matter in one’s occupation (i.e. butcher). This increases susceptibility.

What is the primary lesion of a wart?

Primary lesions include: tiny firm flesh-colored papules that interrupt skin lines or dermatoglyphic lines when on palms or soles. Can also see filiform (threadlike) papules, especially on the eyelid and facial areas.

Warts are diagnosed on their clinical appearance, but a biopsy can be performed if the diagnosis is in doubt. A skin biopsy will distinguish VV from other tumors and growths.
VV displaces the skin lines.

SD can be chronic. It is important to frequently reinforce treatment and maintenance regimens with patients. After the initial visit have patients RTC after 4 weeks.

What is the presentation of Pityriasis Rosea?

Rash abruptly begins with a single 2 to 10 cm round to oval lesion (the herald patch), which is usually salmon colored
The complaint of “ring worm” and the use of OTC antifungal creams.
Within a few days to several weeks (average, 7 to 14 days) the disease enters the eruptive phase. Smaller lesions appear and reach their maximum number in 1 to 2 weeks. This phase tends to resolve over 6 weeks, but variability is common.
*Only one occurance. If reoccurance, think eczema*

What are the primary lesions of Pityriasis Rosea?

Primary lesions include: an erythematous to salmon-colored plaque measuring 1-2 cm in diameter. The first appearing lesion is called the “herald patch.”

What are the secondary lesions of Pityriasis Rosea?

Secondary lesions include: a collarette (or ring) of scale on the papules or plaques

What is the distribution of Pityriasis Rosea?

PR has a macrodistibution and includes the neck, chest, back, abdomen, arms, hips, and proximal thighs

PR has a “Christmas tree” distribution (this means that the lesions appear as a linear descending pattern much like the dropping branches of a pine tree)

How do you differentiate Pityriasis Rosea from Tinea Corporis?

KOH

How do you treat Pityriasis Rosea?

There is no specific therapy. PR is a benign self-limiting disease that resolves on its own in a 6 to 12 week time period. It heals without permanent scars or marks, and recurrence is rare.
The following treatments can be suggested if patients are distressed with extensive lesions:
Medium potency group IV or V steroid cream (triamcinalone cream) used BID x 3 weeks, avoiding face, axilla, and groin, when there is significant itching
UV light
Avoid hot showers, overheating or activity that raises body temperatures. This can increase itching.

PV has a macrodistribution and can occur on any skin surface.
Scattered, discrete lesions, like a rash, are generally concentrated on the trunk and scalp, less on the face, and usually spare the palms and soles.
EXTENSOR surfaces

What are the physical findings of Psoriasis Vulgaris?

Nail changes include pitting, subungal hyperkaratosis, onycholysis, and yellowish-brown spots under the nail plate. (This is called oil spots. Oil spots are is pathognomonic for psoriasis).
Arthritis (in 10% of cases)

How do you diagnose Psoriasis Vulgaris?

The diagnosis of psoriasis is made on clinical grounds. However, a skin biopsy or fungal study may be performed to rule in or rule out other possible diagnosis.
Antistreptolysin titer is increased in acute guttate psoriasis.

A 16-year-old female comes to your office complaining of a pruritic generalized eruption of gradually increasing intensity over the prior 4 months

Scabies

What are the primary lesions of scabies?

Primary lesions include: tiny discrete vesicles and erythematous papules, some of which evolve into burrows (the classic telltale lesions of scabies) in the interdigital webs of the hands, wrists, antecubital fossae, points of the elbows, nipples, umbilicus, lower abdomen, genitalia, and gluteal cleft

What are the secondary lesions of scabies?

Secondary lesions include: excoriations, ulcerations, hemorrhagic crusts and lichenification (these may replace the primary lesions due to the intense itch)

Where is scabies found?

Lesions are found on the finger webs, finger margins, flexor surface of the wrists, elbows, axillary folds and ankles

What are the symptoms of Scabies?

Itching (especially at night) that progressively worsens over 2-3 weeks and can persist indefinitely, thus the appellation, “the seven year itch”
Rash on hands, feet, wrists umbilicus, waistband area, axillae, ankles, buttocks, or groin
Symptoms (rash and itching) in several members in the same family

How do you diagnose scabies?

Diagnosis is made by identifying scabies mites, eggs, egg casings (hatched eggs) or feces (scybala) under the microscope. This is called a ectoparasite examination.

What is Ectoparasite Examination?

A drop of mineral oil is applied to the most likely lesion (usually a vesicle on the finger web or wrist is chosen). The site is then scraped with a 15-surgical blade. (Remember, to scrape con gusto! No bleeding, no bug). The scrapings are placed on a glass slide, a cover slip is applied, and examinated on low power under the microscope.

How do you treat Scabies?

After a warm bath apply permethrin (Elimite cream, Acticin cream) or lindane (Kwell) cream or lotion (only used if other agents fail or are not tolerated) to skin from “head to toe” and wash off 12 hours later, usually overnight. Repeat 1 week later.
Nails should be cut short and medication should be applied under nails vigorously with a toothbrush.
If indicated, other family members and contacts should be treated simultaneously
All bed linen and undergarments should be washed in hot water after treatment is completed

What kind of follow-up should you do with Scabies?

Because of resistance, careful follow-up and a possible second treatment should be considered. Have patients RTC 2 to 4 weeks after treatment. Remember, symptoms or nodules may persist for weeks or months after the mites have been eradicated on the buttocks, groin, scrotum, penis, and axillae.

It is normal to itch for up to 2 months after treatment

Erythema with scale-forming yellowish plaques on the eyebrows, nasolabial folds, glabella, and presternal area best describes:

Seborrheic Dermatitis

An acute eruption of violaceous, pruritic, polygonal, shiny, flat-topped papules involving the flexor surfaces is suggestive of which of the following?

Lichen Planus

Which of the following diseae can affect the skin, nails, and joints?

Psoriasis

A 19-year-old presents with a minimally pruritic rash as seen on the other side.

The lesion on the right arm
was the first to appear
followed a week later by the
remaining lesions.
What is the most likely diagnosis?

No laboratory examinations required. However, if there is a suspicion of endocrine disorder free testosterone, follicle-stimulating hormone, luteinizing hormone, and DHEAS should be tested to exclude hyperandrogenism and polycystic ovary syndrome. (Note: In the overwhelming majority of acne patients, hormonal levels are normal).

What would you expect to see on physical exam of Grade I: Superficial, non-inflammatory?

Open/Closed comedones.

What would you expec to see on physical exam of Grade II: Superficial Inflammation

Comedones, mild to moderate papules/pustules

What would you expect to see on physical exam of Grade III: Deep Inflammatory

Moderate papules/pustules, few nodules

What would you expect to see on physical exam of Grade IV: Severe Nodulystic

Presents with a localized papular and eczematous eruption (scaly) with tiny pinpoint pustules in the perioral, perinasal, or periocular areas of the face
Lacks comedones, nodules and cysts
Topical acne medications will exacerbate the condition
The disease steroids made famous

45 yo female with history of flushing and red face, worse over past 5-6 years, now getting “pimples” and nose looks like “Rudolph’s” in family photos.

Rosacea

How does Rosacea present?

Complaining of episodic flushing, redness, and pimples on the face
Dry or red eyes, scratchiness, burning or tearing, and a sense of a foreign body being in the eye (ocular rosacea may precede skin manifestations in up to 20% of people)
Enlarged blood vessels on the cheeks

What precipitating factors can exacerbate rosacea?

Exposure to sun, stress, spicy foods, alcohol, hot drinks such as coffee, excessive washing of the face, or irritating cosmetics.

What would you expect to see on physical exam with Rosacea?

Papules and papulopustules on the central third of the face (forehead, nose, cheeks, and chin- the so called “flush/blush” areas)
Telangiestases and marked sebaceous hyperplasia
Blepharoconjunctivitis (red, scratchy eyes)
Rhinophyma (enlarged nose)

What serious disease can develop secondary to rosacea?

Corneal ulcers

How do you treat Rosacea?

Patients should be advised to avoid significant environmental triggers
Apply a daily sunscreen
Topical medications such as Metrogel 1% qd or Finacea gel qd are the most frequently prescribed first line therapy. Sodium sulfacetamide and sulfur topicals such as Klaron, Rosac, Plexion are also effective and used BID.

How do you treat Rosacea if topical treatment is ineffective?

If topical treatment is ineffective, an oral antibiotic can be prescribed. Tetracycline 500 mg BID or doxycycline 100 mg BID noticeably improves rosacea within 3 weeks. Oracea, an anti-inflammatory low-dose doxycycline, is also effective and taken 40 mg qd.

How do you treat Rosacea if tetracycline and doxycycline are ineffective?

If tetracycline or doxycycline is not effective there are alternative antibiotics that can be used such as amoxicillin, azithromycin, or clarithromycin
Pulse Dye Lasers and Intense Pulsed Light are light treatments that can be used to destroy larger telangiectatic vessels

Pimples and pustules in hair-bearing areas such as the face, scalp, thighs, chest and body folds. The patient usually describes them as “razor bumps” or “ingrown hairs”.
Sore on the distal nose, near the tip of the nose, or involving an eyelash
Papules may be itchy
Clean gym-strict about cleaning equipment
Treadmill, weight machines
Takes a shower at gym after soaking in hot tub

In cases that are resistant to treatment, a bacterial culture should be done
Culturing and treating of family members should be considered in cases of chronic bacterial folliculitis

How do you treat folliculitis?

Encourage good personal hygiene, including bathing, hand washing, and keeping nails short and clean
Wash with an antibacterial soap such as a benzoyl peroxide preparation (Benzac AC 5% gel or wash)
Apply mupirocin 2% (Bactroban) to the NASAL vestibule TID x 5 days to eliminate the S. aureus carrier state
Treat with Dicloxacillin 250-500 mg QID or a cephalosporin, such as Cephalexin 1-4 g/day in two divided does. Minocycline 100 mg BID or Septra DS BID can be used for MRSA.

Onset is heralded by an aura of itching and burning 12 hours before a visible lesion
Lesions have recurred at approximately the same site each time
The patient clearly describes an evolution from a red welt to bump, blister, and crust
Evolution of each lesion is about 10 days from start to finish

Herpes Simplex Virus

What are the physical findings of herpes?

Vesicular lesions that can ulcerate or form a crust
Infrequently, regional lymphadenopathy occurs

How do you diagnose herpes?

The diagnosis of HSV is usually based on clinical appearance and history. When necessary, however, a Tzanck preparation can be done to determine the presence of HSV or VZV (it does not distinguish between these two viruses).

Oral antivirals must be administered during the prodromal stage (first 48 hours) for optimal results.

Not contagious.
Sharply demarcated rash on hands, elbows, knees.
Blister (HSV) is often aura to EM, but does not cause EM.

Tender, red rash on the face, particularly in and around the nose and mouth
Small bumps with honey-colored crusts or blisters
Itch

Impetigo

Describe the rash/lesions that are associated with impetigo.

Rash that spreads quickly and is poor to heal
Lesions are usually asymptomatic; however occasionally they itch and are painful

What kind of primary and secondary lesions make up impetigo?

Bullae or vesicles with clear contents
Plaques with peripheral scale
Crusts, typically honey-colored, but sometimes brown or hemorrhagic
Begins as a crust or thin-roofed, fragile vesicle or bulla that ruptures, leaving a oozing eruption capped with a thick, “honey-crusted” lesion that appears “stuck on”

What non-lesion physical findings are associated with Impetigo?

Regional lymphadenopathy
The face is commonly involved, particularly in and around the nose and mouth
Loose white peripheral scale
Hypopigmentation once rash is resolved
Hyperpigmentation once rash is resolved

How do you diagnose Impetigo?

Diagnosis is based on history and clinical appearance
Bacterial culture and sensitivity testing are recommended if standard topical or oral treatment does not result in improvement
50% of patients may have an increased white blood count

How do you treat Impetigo?

Use antibacterial soaps twice daily
Use a warm washcloth and antibacterial soap to gently remove the crusts. Crusts should be removed because they block the penetration of antibacterial ointments. Lesions can also be soaked in warm water TID to help soften crusting and ease debridement.
Apply Mupirocin 2% (Bactroban) ointment or cream TID to lesions and INSIDE OF NOSTRILS until lesions are cleared, usually 10 days. Once clear, mupirocin 2% ointment can also be applied inside the nostrils TID x 5 days each month to reduce bacterial colonization in the nares.
Use an oral antibiotic, such as cephalosporin (Keflex) 250 to 500 mg QID x 7 days or dicloxacillin 500 mg BID x 7 days in conjunction with topical antibiotics in those patients with widespread involvement. If bacterial cultures reveal MRSA tetracyclines, trimethoprim/sulfamethoxazole (Bactrim), clindamycin, or linezolid are effective oral antibiotics.
Good hygiene and hand washing should be encouraged. Household spread is common otherwise. If skin care is not reviewed with the patient, the chance of re-infection or persistent infection is high. Skin care details should include adjuvants to topical antibiotics. The easiest adjuvants to use for patients are the bleach bath (1 cup of bleach in a bathtub of 12 inches water and with supervision), mixing vinegar and water at a 1:4 ratio for rinsing the area, and chlorhexidine scrubs.

If there is a question of tinea, perform a KOH to differentiate between tinea and eczema

How do you treat Atopic Dermatitis (Nummular Eczema)?

Lubricate the skin with an emollient (Cetaphil cream, CeraVe cream) TID and immediately after bathing
Eliminate excessive lengthy bathing, hand washing, and abrasive washcloths. Use a gentle soap (Cetaphil) while bathing.
Do not scratch
Use Group V steroid creams of ointments for red, scaling skin BID x 2 weeks. Use I or II creams or ointments for lichenified skin BID x 2 weeks. When the condition is under control, the frequency and potency of the topical steroid is reduced and discontinued.
Antibiotics may be used to suppress S. aureus. Use cephalexin (Keflex) 500 mg BID x 10 days or Dicloxacillin 500 mg BID x 10 days.
Minimize airborne allergens and dust
Antihistamines are useful in treating children with coexistent allergies, hives or allergic rhinoconjunctivitis
In severe cases, use Prednisone 1mg/kg x 10-14 days
Phototherapy can induce remission in patients with recalcitrant chronic atopic dermatitis

How does the sliding scale treatment work for atopic dermatitis?

Ask the patient to point out pink, red, and white spots:
Basic Rules:
Short nails, short bath (3 min), cotton clothing, and cool environment; laundry- hypoallergenic detergent with no bleach or fabric softener
Bath care:
Antibacterial soap to skin from the neck down (do not use on face) for three minutes
Bath with one ounce of emollient bath oil for 3 minutes
After bath, pat dry. Do not rub. Apply emollient to entire body.
Morning:
Emollient to entire body, even if no inflammation (nothing red or pink).
AND
Medium strength topical steroid to red areas on body
Lower strength topical steroid to slightly red or pink areas on body
Lower strength topical steroid to pink or red areas on face
Afternoon
Emollient to all skin.
Evening
Emollient to entire body, even if no inflammation (nothing red or pink on body).
AND
Medium strength topical steroid to red areas on body.
Lower strength topical steroid to slightly red or pink areas on body.
Lower strength topical steroid to pink or red areas on face.

Why wouldn't you use Triamcinalone for eczema?

Too potent for face
Not potent enough for body
Overwhelms antifungal properties in combo
Wrong vehicle in wrong place
Wrong medicine for wrong diagnosis
Too many large tubes with too many refills
Patients use it for other problems when not often indicated

What are three key differential features of allergic contact dermatitis (to differentiate between atopic dermatitis?)

More localized distribution
Varied spectrum of pruritis
No family history of atopy

What are the differential features of Dyshidrotic Eczema/Pompholyx?

>5% of all hand eczema cases
Recurrent vesicles and fissures
Symmetric over hands and feet
Regular hand barrier therapy important

Annular patch with distinctive raised, red, scaling, snake-like border, clearing areas in the center.
Lesions are annular, single or multiple, with central clearing, and a scaly “active border”

Tinea Corporis

Inflamed, scaly patches with areas of hair loss or hairs that are broken off close to the surface of the scalp (often called “black dot”). Tender pustular nodules or plaques called kerions may occur.

Tinea Capitis

lesions are bilateral, fan-shaped, or annular plaques with a slightly elevated scaly “active border”. It generally involves the upper thighs, the crural folds, and pubic area and buttocks but spare the scrotum and penis.

The main symptoms are reddish-brown slightly scaly patches with sharp borders. The patches occur in moist areas such as the groin, armpit, and skin folds. They may itch slightly and often look like patches associated with other fungal infections, such as ringworm.

Erythrasma

What bacteria causes erythrasma?

Corynebacterium minutissimum

How do you diagnose Erythrasma?

Examination with a Wood’s lamp will usually produce a pink or coral-red fluorescence
KOH is negative

A common superficial YEAST caused by the hyphal form of Malassezia furfur (previously known as Pityrosporum ovale and Pityrosporum orbiculare)

Patients present because of cosmetic concerns about their “blotchy pigmention” otherwise seen as hypopigmented or hyperpimented macules on the upper back, chest, arms, face, and legs
Occasionally, mild pruritis

SCRAPE!
KOH examination is positive, which have been described as having the appearance of “spaghetti and meatballs”
Wood’s light examination is used to demonstrate the extent of the infection and my help to confirm the diagnosis, because lesions often fluoresce an orange-mustard color when the Wood’s light is help close to lesions in a dark room

How do you treat Tinea Vesicolor?

Topical treatment includes: Ketoconazole 2% shampoo applied for 10 minutes daily, followed by a shower, or selenium sulfide suspension 2.5% applied for 10 minutes, followed by a shower, every day for 7 consecutive days
Oral treatment may be used in patients with extensive disease and those who do not respond to convention treatment or have frequent recurrences. Options include a single dose of Ketoconazole (Nizoral) 400 mg and repeated in 7 days if needed or Fluconazole (Diflucan) 300-400 mg given as a single dose and repeated if needed after 2 weeks.
Prophylactic application of ketoconazole cream or shampoo once or twice weekly may prevent recurrences

Idiopathic, asymptomatic, ring shaped grouping of dermal papules
Lesions are skin-colored or red firm papules, with no epidermal change (scale)
Although any part of the cutaneous surface may be involved, lesions are most often symmetrically distributed on dorsal surfaces of hands, fingers, feet

Graunuloma Annular

How do you treat Granuloma Annular?

The patient should be reassured of the benign nature of this condition
Potent topical steroids
Intralesional triamcinolone acetonide (Kenalog) in a dose of 2 to 4 mg/mL with a 30-gauge needle. This may be repeated in 4 to 6 week intervals.

Sometimes with a punch biopsy, the GA will go away.

Itching is produced by sensory nerve irritation as it turns sharply and enters the spinal canal
No cutaneous manifestations in acute cases
Lichenified and hyperpigmentation seen in chronic cases
Treatment: Inexpensive back scratcher!

Mupirocin (Bactroban) ointment is indicated for the treatment of a localized case of:

Impetigo
Atopic Dermatitis
Tinea Pedis
Cellulitis

Impetigo

Which of the following does NOT exacerbate the flushing of rosacea:

Cigarette smoking
Stress
Caffeine
Spicy foods

Cigarette Smoking

Comedonal acne is best treated with:

Benzoyl peroxide
Topical antibiotics
Oral antibiotics
Retinoids

Retinoids

How do you know if a lesion is worrisome?

First, know what normal looks like!
Second, ask questions
Is it changing in size, color, or shape?
Is it bleeding?
Does it “come and go” or does it stay?
How long has it been there?

Generally flat (macule) brown with melanocytic nests at the junction of the dermis and epidermis

Junctional Nevus

Brown papule with combined histiologic features of junctional and dermal nevi

Compound Nevus

Skin colored or light brown (pinkish) raised (papule) with nests of melanocytes in the dermis

Dermal Nevus

Well circumscribed, round or ovoid lesions
2-6 mm in diameter
Lesions vary greatly in size, histologic characteristic overlap, surface appearance, hair or no hair
Blue, red, gray and black are not usually seen in these nevi

Most common macules, papules, plaques over the age of 30
Verrucous, waxy, velvety- tan black
“Stuck On”
Face, neck, trunk not palms, soles, or mucous membranes
Single, but often multiple
Not true moles
Thickened epidermis basaloid or squamous cells
Various colors white, pink, brown, black and all in between

If there is any question regarding the clinical diagnosis, shave biopsy (removal) is imperative
Some will describe irritation, itching… when removing, important to note irritated seborrheic keratoses and method of removal for insurance purposes
Cryotherapy is appropriate, with immediate follow-up if the lesion has not resolved in 30 days

Fibrous growth found on the distal limbs and upper back
Irregular tan pigmentation and a fuzzy border
Palpation will reveal a firm button-like tumor in the dermis and, with lateral compression, the lesion will depress downward (a positive “pucker” sign)

Dermatofibroma

Usually bright red
May be multiple
Asymptomatic
Middle-age to elderly
Trunk> extremities

Can remove with cauterization

Cherry Angioma

Very common in persons will oily complexions
Rasied papules with a central dell 3 to 7 mm in size
White or yellowish in color
Central face > trunk
May mimic basal cell carcinoma (BCC)

Sebaceous Hyperplasia

Dark red-violaceous
Elderly
Blanchable
Soft
On the lips and ears

Venous Lake

Venous Lake

Caused by inflammed cartilage secondary to sun exposure

Chondrodermatitis nodularis chronicua helicus (CNH)

Most common form of skin cancer
Pearly boder with telangestasia on outer rim, not in center.
Metastasis is rare and usually associated only with tumors that have been neglected
Treatment is needed to prevent local destruction of normal tissue
A suspected BCC should be biopsied both to establish the diagnosis and treatment

Earliest lesions of squamous cell carcinoma (SCC) in sun damaged skin
More easily palpated than seen
Rough texture like sandpaper
Pinkish color: varying sizes
Sometimes will be tender or pruritic; most often asymptomatic
Usually multiple
If untreated, these lesions may progress into a squamous cell carcinoma

Actinic Keratosis

(If a presumed actinic keratosis has recurred after 2 treatments, a biopsy is warranted to rule out squamous cell carcinoma.)

Treating Actinic Keratosis (AK)

Liquid nitrogen: “freezing” or “burning”, causes focal ‘frost bite’ destroying the abnormal tissue, allowing the area to heal with healthy epidermis
Topical chemotherapy: application of a topical agent, usually over 3-6 weeks, that will destroy the trouble spots. This is useful when it is difficult to determine the borders of the lesion or when there are too many lesions to destroy individually.

Erythematous keratotic papule
Sun-damaged skin
Slow or rapid growth
May bleed or ulcerate
May metastasize
Malignant neoplasm of keratinocytes derived from the epidermis in which tumor cells have invaded the dermis
May invade locally into fat, muscle, bone or cartilage
Can metastasize to regional nodes and distant sites
Is generally slow growing

Squamous Cell Carcinoma

Keratotic, crusted nodule in sun-exposed area
Most frequent risk factor is chronic UV damage
Treatment similar to BCC
Most common skin cancer in immunosuppressed patients

A 1-cm pearly papule with central umbilication and telangiectasias on the left temple of a 67-year-old male is most likely:

Rosacea
Basal Cell Carcinoma
Impetigo
Sebaceous gland hyperplasia

Basal Cell Carcinoma

Spitz Nevi

Spitz Nevus

Squamous Cell Carcinoma

Squamous Cell carcinoma

Keratocanthoma

Keratocanthoma

Dermatofibroma

Basal Cell Carcinoma

Basal Cell Carcinoma

The use of cold temperature to treat disease
Cause epidermal-dermal separation above the basement membrane
Stinging, burning pain that peaks during thawing (about 2 minutes after treatment is over)
Intense edema or a blister forms 3 to 6 hours later, flattens in 2 to 3 days, and sloughs off in 2 to 4 weeks